Library

[Etiology] There are two types of Jue (syncope/cold extremities): Yang Jue and Yin Jue. Yang Jue is also known as Heat Jue. It must first transmit from the Three Yang meridians into the Yin compartments. Therefore, at the onset, there must be headache and fever. The pathogen moves from shallow to deep, then affects the Three Yin meridians, resulting in cold extremities that may temporarily warm up. This syndrome is caused by internal binding of evil heat or failure to purge latent yang. Yin Jue is also known as Cold Jue. Initially, there are no excess-heat syndromes characteristic of meridian transmission from the Three Yang meridians. Zhang Zhongjing stated: "In all cases of Jue, the yin and yang qi fail to connect smoothly, which constitutes Jue. The manifestation of Jue is cold extremities."

[Symptoms] In the initial stage of Yang Jue, there must be headache and fever, after which the pathogen enters the Three Yin meridians, transforming into cold extremities that may temporarily warm up. Symptoms must include constipation, restlessness, delirium, thirst, aversion to cold being absent but aversion to heat present. Wu Yunfeng said: Yang Jue occurs when external contraction of the Six Evils initially presents with headache, body heat, dry mouth, and rapid pulse. It may suddenly become cool and cold, resembling a Yin syndrome. However, the coldness does not extend beyond the elbows and knees, and lasts only for a short time. Stool is closed, eyes are red, and urine is dark red. This indicates heat pathogen entering the interior, where qi and blood cannot circulate freely. This is what is called "Extreme Yang leading to Jue," where extreme fire resembles water. Symptoms of Yin Jue include aversion to cold, cold extremities, abdominal pain, vomiting and diarrhea, tremors, absence of thirst, and a deep, forceless pulse. This is Jue reversal due to yin-cold, characterized by yin without yang, hence named Yin Jue. Wu Yunfeng said: Patients with Yin Jue typically have internal cold, or have consumed cold food, or contracted cold pathogen, or suffered spontaneous sweating and diarrhea after illness, leading to cold body and extremities, fatigue, desire to lie down, absence of thirst, cyanotic complexion, clear urine, and a deep, fine, slow pulse. Suddenly, they become restless and agitated, desiring to sit in mud or well water. This is "Extreme Yin leading to agitation," where yin exhaustion resembles yang. Zang Jue (Visceral Jue) syndrome: Zhang Zhongjing said, "In Shanghan, if the pulse is faint and there is Jue, and by the seventh or eighth day the skin is cold, and the patient is restless with no moment of peace, this is Zang Jue. Such patients must have heart and abdominal pain. Zang Jue is a death syndrome because yang qi has been exhausted." Hui Jue (Roundworm Jue) syndrome: The patient should vomit roundworms. The patient is quiet but occasionally becomes irritable; this is due to visceral cold, causing roundworms to move upward into the diaphragm, causing irritability. After a while, it stops again. Vomiting occurs after eating, accompanied by irritability, because the roundworms come out upon smelling food. The patient should spontaneously vomit roundworms. Hui Jue is treated with Wumei Wan (Mume Pill). Cheng Wuji said: Although Hui Jue presents with Jue and irritability, the irritability ceases once the roundworms are vomited, unlike Zang Jue where restlessness knows no pause. Since the patient's viscera are cold and stomach qi is deficient, Wumei Wan is appropriate to warm the viscera and pacify roundworms. This is Zhang Zhongjing's discussion on Jue. However, the discussion of Jue in *Neijing* differs; it refers to sudden collapse, coma, cold extremities, pale complexion, clenched jaw, resembling wind-stroke but without deviation or convulsions. "Jue" means exhaustion; "Ni" (reversal) means chaos, referring to the disorder of qi and blood. Zhang Jingyue said: When Jue is about to occur, coldness, heat, and numbness must begin in the extremities. Sudden collapse, cold extremities, lusterless complexion, coma, clenched jaw, or submerged six pulses resemble wind-stroke but lack phlegm sounds and convulsions.

[Pulse] In all cases of Yang Jue due to Shanghan, the pulse is deep and forceful; in Yin Jue, the pulse is deep and forceless. Li Shicai said: In Yin Jue, the pulse is deep and weak, nails are cyanotic and cold; in Yang Jue, the pulse is deep and slippery, nails are red and warm. In Zang Jue, the pulse is faint and Jue is present; the cunkou pulse is deep, solid, slippery, and large, indicating excess syndromes like Phlegm-Qi-Jue or Food-Jue; a faint, soft, and wiry pulse indicates deficiency syndromes like Yin-Yang Deficiency Jue. Pulse varying in size indicates Shi Jue (Corpse Jue); deep, fine, and forceless pulse indicates Hui Jue; floating and large indicates Wind Jue; tight and fine indicates Cold Jue; hollow and rapid indicates Summerheat-Heat; hurried and urgent indicates Miasma-Dampness; choppy and stagnant indicates Blood Reversal; absence of pulse indicates Yuan Qi depletion.

[Treatment] If Yang Jue is mild, the heat is also mild; use Sini San (Bupleurum, Peony, Immature Bitter Orange, Licorice). If Jue is severe, the heat is also severe; use Chengqi Tang or Sanhuang Shigao Tang. For Cold Jue due to middle-jiao cold, mild cases use Lizhong Tang; severe cases use Sini Huayang Decoction and others. For Cold Jue, use Sanjian Tang (Aconite, Prepared Aconite, Heavenly Aconite, decocted with fresh ginger), add Ginseng. (Xu Rongzhai notes: *Neijing* emphasizes Yuan Qi in discussing Jue, so Heat Jue requires nourishing yin, and Cold Jue requires tonifying yang. *Shanghan Lun* focuses on pathogenic factors, so Cold Jue requires warming, Heat Jue requires clearing, and purgation may even be used. This treatment is based on differentiation according to *Shanghan Lun*.) For Hui Jue, use Lizhong Tang added with stir-fried Mume and Sichuan Pepper. Jian Jue (Frying Jue) caused by excessive mental labor, with yang expanding outward and yin essence depleted internally, should be treated with Liuwei Dihuang Tang added with Anemarrhena, Phellodendron, and Tortoise Shell. If caused by deficiency and decline of yuan qi, failing to control ministerial fire, leading to confusion and sudden collapse with a soft and rapid pulse, use Shenren Tang (Ginseng, Astragalus, Rehmannia, Ophiopogon, Schisandra, Asparagus, Phellodendron, Honey-fried Licorice). Bo Jue (Thin Jue) caused by great anger severing form and qi, with blood stagnating in the upper jiao, leading to Bo Jue, should be treated with Xijiao Dihuang Tang added with blood-invigorating and qi-descending herbs, or Bawei Shunqi San (Ginseng, Atractylodes, Green Tangerine Peel, Tangerine Peel, Poria, Angelica Dahurica, Lindera, Licorice). Tan Jue (Phlegm Jue) presents with sudden chest oppression, phlegm rattle, salivation, cold extremities, and a deep-slippery pulse. Severe cases remain unconscious, called Phlegm Obstruction; mild cases gradually wake, called Phlegm Jue. Use Daotan Tang (Prepared Pinellia, Prepared Arisaema, Immature Bitter Orange, Poria, Tangerine Peel, Licorice, Ginger). Or Sijunzi Tang added with Bamboo Sap and Ginger Juice. Shi Jue (Corpse Jue) is caused by exposure to malignant qi, such as climbing high temples, attending funerals, or sudden exposure to foul air, leading to cold extremities, clenched jaw, fainting, and delirious speech. Treat with Suhexiang Wan, administered with Ginger Juice. Fumigation with Vinegar Charcoal can also revive the patient. Qi Jue has two types: Qi Deficiency and Qi Excess. Excess type presents with angry qi, sudden collapse, cold extremities, no salivation, and deep-wiry or submerged pulse. Treatment should soothe qi and regulate liver, using Simo Yin or Wuyao Shunqi Tang. This differs greatly from wind-stroke with warm body and abundant salivation. Deficiency type presents with exhausted qi and form, cyanotic complexion, weak pulse, and slightly cold limbs. Treatment should strongly tonify yuan qi, using Buzhong Yiqi Tang or Bazhen Tang. Xue Jue (Blood Jue) also has two types: Blood Reversal and Blood Loss. Blood Reversal often occurs postpartum after anger, where blood follows rebellious qi. Regulate qi first, similar to Bo Jue. When qi moves, blood moves. Severe cases use Tao Ren Chengqi Tang. Blood loss, such as massive hematemesis or metrorrhagia, or excessive lochia postpartum, causes qi to scatter with blood, leading to sudden collapse and unconsciousness. First pinch Renzhong or burn vinegar charcoal to gather qi, then urgently administer a large dose of Dushen Tang (Single Ginseng Decoction). This is the method of benefiting qi in blood loss. (Xu Rongzhai notes: For blood reversal causing Jue, Baiwei Tang can be used—Baiwei 1 liang, Danggui 1 liang, Renshen and Gancao 1 qian each, decocted in water.) Jiujue (Alcohol Jue) caused by drunkenness is treated with Gehua Jieying Tang. Shijue (Food Jue) caused by overeating, where after heavy meals, exposure to wind-cold, or anger, food blocks the chest, stomach qi fails to descend, leading to sudden Jue. Symptoms include coma, inability to move limbs, and rapid/large or submerged kou pulse. First induce vomiting with salt water; if unsuccessful, it is critical. Then treat with mild resolving formulas like Erchen Tang added with Zhi Ke, Hou Po, Shan Zha, and Shen Qu. Jue due to sexual intercourse often leads to untreatable collapse. In men, it is called Tuoyang (Yang Collapse), treated with Shenfu Tang added with Deer Antler. If the penis remains erect after death, it is called Tuoyin (Yin Collapse) in women, treated with Shenfu Tang combined with Guilu Erxian Jiao. Jue due to nocturnal emission is called Tuoyuan (Yuan Collapse), with erection and emission, facial expression of pleasure, and warmth; treat with Shenfu Tang added with Shu Di Huang, decocted urgently. If cold, it is untreatable.

[Xiu's Commentary] *Neijing* states that yang deficiency below leads to Cold Jue, characterized by cold limbs, deep/faint/rapid pulse, or rapid but forceless pulse, often presenting as apparent heat but not true heat. Thus, any cold extremities without excess-heat signs are Cold Jue. Use Yiyuan Tang or Fuzi Lizhong Tang. Yin deficiency below leads to Heat Jue, starting with much heat, deep/slippery/rapid pulse, aversion to heat, preference for cold, irritability, constipation, and coma-like symptoms. Caused by sex after drinking, damp-heat sinking, fierce alcohol qi, declining kidney water, dominant yang, and drying yin fluids, leading to Jue. Nourish the master of water using Liuwei Dihuang Tang. Since Foot Three Yang meridians start at toes and Foot Three Yin converge at sole, Heat Jue starts from feet, and yin-deficiency diseases often have hot soles. Cold Jue starts at five toes and rises to knees; thus, yang-deficiency diseases have cold limbs. Therefore, warming yang for Cold Jue and nourishing yin for Heat Jue aligns with Wang Bing's method: "Nourish the master of water to control hyperactive yang; benefit the source of fire to eliminate yin shadows." *Neijing* says: "When blood and qi rush upward together, it is Great Jue. Jue implies sudden death." Also: "Internal depletion leading to Jue is Fei (flaccidity). This is kidney deficiency." Some call it Kidney Jue. Shen Youpeng said: Jue is sudden collapse due to lower qi rebelling upward. *Neijing* says: "If qi returns, life; if not, death." Meaning qi returns downward, not disperses and re-aggregates. Chapter one describes symptoms; chapter two etiology—one due to kidney, one to liver. *Neijing* says internal depletion originates in kidney. Kidney stores essence (true yin), containing true yang. Kidney channels attach to tongue root. Yang likes ascending, relying on yin to anchor. If essence is depleted, yang has no basis, ascends, saliva rebels with qi, blocking tongue channels, causing aphasia. With yang ascending, lower jiao yang is weak, causing foot flaccidity. Abstaining from sex and anger prevents Great Jue. *Neijing* says great anger originates in liver. Liver is wind-wood organ, likes ascending, channels go through throat to vertex. Adequate essence/blood anchors liver yang; anger won't cause Great Jue. Only those with deficient essence/blood lack anchoring; liver yang moves easily, rising violently with anger, depleting lower jiao qi, causing collapse. Upper jiao qi congestion causes aphasia. This is Great Jue or Sudden Jue. This explanation is correct. Wu Yunfeng said: Hui Jue patients have roundworms in stomach, suffer cold/stomach injury, hunger, or improper sweating causing stomach cold, worms moving to diaphragm, dry tongue/mouth, rinsing without swallowing, irritability, coma, cold extremities, vomiting worms. Use Lizhong Anhui Tang (Ginseng, Atractylodes, Poria, Stir-fried Sichuan Pepper, Mume, Ginger). Avoid Licorice and sweet foods, as worms move with sweet, settle with bitter, calm with sour, and hide with pungent. Food blocking Taiyin causing abdominal pain and worm vomiting should be treated with warming middle and resolving stagnation. Warm body with sweat in Jue indicates entry into fu organs (survival); cold body with cyanotic lips indicates entry into zang organs (fatality). Cold hands past elbows or feet past knees is fatal. Red nails indicate survival; black/blue indicates death. Sudden vomiting of purple-red phlegm in early or late stage is fatal. Open mouth and scattered hands indicate five-viscera extinction; large doses of Ginseng and moxa on Qihai/Dantian may save some.

[Lian's Commentary] Jue is a disease reversing from below upward. Only Juozheng Fanhun Dan (formula see previous section) can govern all Jue. Shao Xinpu said: Generally, Jue arising from miscellaneous diseases differs from that in Shanghan chapters. This condition arises from daily deviation of qi and blood, forming yin and yang simultaneously, like violent wind and thunder erupting from extreme depression. If recovery is gradual after onset, danger can turn to safety; if deterioration follows, roots will be pulled out, leading to death. Survival depends on the fullness or emptiness of Mingmen. Medical books have various names and complex etiologies. Those suitable for emesis, like phlegm/food blocking chest, use Genti San or burnt salt induction. Those suitable for clearing/reducing, like Jueyin strong fire rebelling unchecked, use Yuniu Jian or Xuanming Longhui Wan. Those suitable for opening/descending, like Qi Jue or Bo Jue with sudden qi/form cessation, use Wumo Yinzi or Changpu Wine. For turbid pathogens clouding mind causing confusion, use Niuhuang Zhibao Dan or Suhexiang Wan. For Flying Corpse Sudden Jue, guide with wine/vinegar, apply acupuncture/moxibustion. For deficiency-based Jue, like internal depletion causing Fei or Wind Jue, use Dihuang Yinzi to connect lower jiao. For Jian Jue from mental labor and yang expansion, use Renshen Guben Wan with gold leaf. For Xue Jue with boiling collaterals, refer to yin/yang methods. For Se Jue with essence depletion below, urgently use large-dose Yuan-rescuing methods. For Kidney Jue, follow Xu Xueshi's Jiaofu to unblock yang. For Hui Jue, follow Zhongjing's method to pacify worms. Extreme yang uses severe yin-nourishing agents; extreme yin uses yang-supporting methods. These approaches are comprehensive. Refer to Ye Tianshi's cases for clarity. Xiangyan focused heavily on liver for this condition. Liver is the General, superior to other organs. Once liver qi rebels, all qi rebels. Qi rebellion generates phlegm, fire boils, wind spins, confusing spirit and soul. If attacking upward, it insults lung and scorches fluids; use Maidong Tang or Qiongyu Gao to tonify metal and soften restriction. If attacking middle, causing vomiting/bloating, use Liujunzi Tang minus Atractylodes, add Mu Gua, Ginger, Peony, or Fuzi Jingmi Tang plus Ginseng to tonify stomach and consolidate liver. If shaking heart/spleen causing palpitations/emaciation, use Ganmai Dazao Tang combined with Dragon Bone/Oyster Shell for calming and sedating. If involving Shaoyang attacking vertex/collaterals, use Antelope Horn, Uncaria, Scrophularia, Forsythia to extinguish wind and clear collaterals. If intrinsic organ disease with disharmony of substance/function, use Pepper, Mume, Cinnamon, Peony to benefit substance and promote function. If mother organ deficiency disturbing daughter organ, use Santian, Turtle Shell, Magnetite, Cinnabar, or Guizhi Fuling Lingzhi Tang variants to secure mother-daughter relationship. Wei Jue methods are magical, using animal/shell materials converted to paste for rapid efficacy. This supplements predecessors and opens doors for students. Do not ignore these when studying Ye's cases. Zhu Suisheng noted: Wu's description of ice-cold and fire-hot refers to Jue-Ni (Reversal Jue). *Neijing*'s Great Jue, Bo Jue, Yang Jue, Wind Jue, Yin Jue, Shi Jue require methods to unblock yin and admit yang, descend qi, calm liver, open orifices, move blood, and resolve phlegm. Mrs. Wang had Qi Jue, unconscious, stiff legs, erratic arm movements, undetectable pulse. Treated with Tieluo Yin and Zijin Ding, revived immediately. Recurred three times in two years, treated similarly with success. On the 11th day of the 12th lunar month in Yisi year, Mrs. Sha suffered strange illness, bones rattling like drums, uncontrollable shaking, requiring multiple people to hold, slurred speech, claiming head stolen nine miles away, exorcists busy. Pulse normal. Thinking "all wind/tremors/dizziness belong to liver," Foot Jueyin transmitting to Hand Jueyin allows wind pathogen to attack Heart Pericardium and close orifices. Used red-hot iron hammer quenched in water to decoct Uncaria and Peony, mixed with Zijin Ding, administered. Consciousness returned, shaking stopped. This is also a type of Jue disease.

[Rongzhai's Note] Cold Jue uses Sini Tang; Heat Jue uses Sini San. Scholars of *Shanghan Lun* know this; however, how to differentiate them and what is the key to differentiation deserves study. Predecessors Cheng Wuji, Yu Jiayan, and Lu Dingpu had profound experience. Cheng Wuji said: "If Jue begins with cold extremities not warming, it is yin meridian pathogen with insufficient yang, use Sini Tang. If extremities start hot then become cold (from Si Ni to Jue), it is transmitted pathogen, use Sini San." Yu Jiayan said: "If Shanghan starts with fever, consuming fluids, dry nose, thirst, constipation, gradually leading to Jue, it is obviously heat. If yang syndrome suddenly turns to yin Jue, one in ten thousand. Yin Jue comes from yin syndrome, directly striking true yin meridians, cyanotic lips, white face, cold sweat, loose stools without thirst, fatigue, sleepiness, clear mind upon waking; vastly different from transmitted heat in Shanghan progressing deeper with confusion." Lu Dingpu said: "Jue has yin and yang types. Li Shicai said Yin Jue pulse is deep/weak, nails cyanotic/cold; Yang Jue pulse is deep/slippery, nails red/warm. I say yin syndrome resembling yang cannot rely solely on deep/weak pulse and cyanotic/cold nails. If symptoms show irritability wanting to strip clothes or sit in mud, pale yellow tongue coating, dry mouth/swollen gums, flushed face like slight intoxication or migratory malar flush, weak speech, poor appetite/chest fullness, thirst for water or sore throat seeking water but unable to drink, surface heat but deep pressure reveals no heat or feels cold, or body heat desires clothing; plus cold feet, clear urine, pure grain diarrhea; pulse deep/fine or floating/rapid, scattering on pressure, or floating/large but forceless on pressure. Use warm agents, take medicine cool to follow its nature." The first two distinguish yin/yang Jue; the third identifies yin Jue resembling yang, finding differences amidst similarities with precision. Regarding Se Jue, Mao Tuizhi's *Zhongxiyi Hua* records: "Se Jue patients are originally deficient, exerting themselves during rare encounters or long-term lustful indulgence; afterwards, qi departs with essence, leading to sudden collapse without return." I consider this "Se Tuo" (Sexual Collapse) because the cause is "qi departing with essence," presenting as "sudden collapse" rather than "Jue reversal." Another type develops later, described in medical books as: "Essence lost frequently, collapse gradual, appearing 2-3 days after sexual desire. Because it doesn't appear immediately, it's ignored, and people hide it, unaware many get sick from this after middle age; this is Se Jue. Doctors misdiagnose as wind-stroke! Treatment should cultivate Mingmen, tonify yuan qi with Ginseng/Astragalus, fill true yin with Rehmannia, Angelica, Cistanche, Goji." This aligns with Lianchen's "urgent large-dose yuan-rescuing method." For Shi Jue, ancient methods use Suhexiang Wan. Shen Fengjiang recorded an experience in *Yiyan Suibi*: "South gate surname..."